Surgery, The Ultimate Placebo: A Surgeon Cuts through the Evidence

Summary

For many complaints and conditions, the benefits from surgery are lower, and the risks higher, than you or your surgeon think. In this book you will see how commonly performed operations can be found to be useless or even harmful when properly evaluated. That these claims come from an experienced, practicing orthopedic surgeon who performs many of these operations himself, makes the unsettling argument particularly compelling. Of course no surgeon is recommending invasive surgery in bad faith, but Ian Harris argues that the evidence for the success for many common operations, including knee arthroscopies, back fusion or cardiac stenting, become current accepted practice without full examination of the evidence.

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Surgery, The Ultimate Placebo - Ian Harris

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Acknowledgements

INTRODUCTION

THIS BOOK BUILDS a case for a placebo effect of surgery, something that is often underestimated when assessing the effectiveness of surgical procedures. This placebo effect is one of the factors contributing to the overestimation of the true effectiveness of surgery.

The aim of the book is to inform people, medical and non-medical, about the facts relating to the true effect of many of the surgical procedures performed today and in the past, and to provide a counter to the assumptions that any new operation must be better than the old one; that complexity in surgery is rewarded by increased effectiveness; and that a doctor would not recommend an operation unless it was effective and in the best interests of the patient. But to ensure that you do not take these comments the wrong way, some clarification is in order.

I am not suggesting that all surgery is ineffective or harmful. I am a surgeon and I spend a considerable part of my working life performing surgery. I am, however, a fairly conservative surgeon and tend not to operate when there is doubt about the balance of risks and benefits of a procedure. I rarely regret advising patients against surgery, and I am frequently surprised at how well the body repairs and adjusts itself without surgical intervention. Just as frequently, I see patients who have had questionable operations that have gone wrong, often resulting in the patient being worse off than they would have been without the surgery. It is fair to say that I am sceptical of many of the claims of surgery, because to be sceptical is to be scientific, and because scientific inquiry so often shows the effectiveness of many treatments to be less than initially claimed. In other words, I am sceptical because it is scientific, but also because my scepticism is so often rewarded.

Also, I am not suggesting that surgeons are recommending operations knowing that the potential risks outweigh the potential benefits. Largely, surgeons believe that they are doing the right thing, but often they are not aware of the strength (or weakness) of the supporting evidence or, what is more often the case, there is simply no substantial or convincing scientific evidence available, leaving them to rely on judgments based on their own perception. Without good scientific evidence, surgeons perceive the procedures they recommend to be effective, or they assume that they are effective – otherwise their colleagues wouldn’t be doing them, right? Put simply, a lack of evidence allows surgeons to do procedures that have always been done, those that their mentors taught them to do, to do what they think works, and to simply do what everyone else is doing. It is very hard to get into trouble if you are doing what is common practice and what has traditionally been done. My argument is that relying on tradition and unsupported perception frequently leads to an incorrect assessment of the effectiveness of the treatment, and is therefore not good enough.

I know this because I have learned it the hard way. When I started training and then practicing as a surgeon, decision making was relatively easy; paradoxically, the more you know, the harder it gets. This is because a conflict develops between what you understand to be true, based on scientific research, on the one hand, and what you observe, what you were taught, and what everyone else is doing on the other.

I have always been impressed by the scientific debunking of non-scientific beliefs. I remember many years ago, seeing a television program where two wellknown sceptics (James Randi and Dick Smith) showed water diviners to be no better than chance at detecting water in underground pipes, constructed as part of an experiment. The water diviners felt that they had been about 90 per cent correct, but were only just over 10 per cent correct, in picking water from one of ten pipes.

While I loved the scientific method used, I was fascinated by the reaction of the water diviners, who claimed interference from underground magnets and other things, despite being able to ‘detect’ water in the pipes in prior, ‘open label’ (unblinded) tests. Water diviners, using forked sticks or other devices, had been finding water pretty successfully for generations, and relied on tradition and observation to justify what they knew: that water divining was a good way of finding water. The fact that you could find water just about anywhere if you dug deep enough was not considered. They were just doing what they had always done and it worked – they were finding water. To them, if science showed water divining to be ineffective, it meant that there was something wrong with the experiment; the science was wrong.

I started my career like the water diviners: doing what everyone else was doing and what I was taught to do. And I was happy. And I thought my patients were happy, and most of them probably were. I was finding water, so I didn’t see much point in questioning the methods.

I started doing my own small-scale research (randomised trials comparing two treatments) to fill some gaps in the evidence, but soon became frustrated with my poor understanding of the scientific method. I was jealous of those who could critically appraise scientific studies. I didn’t even know there was ‘good’ and ‘bad’ science, let alone possess the ability to be able to distinguish between the two. I set out to obtain that knowledge, and in doing so I quickly realised that that the scientific method (so called ‘evidence-based medicine’) was the only way of reliably knowing things – that there were significant flaws in relying on observation and tradition.

In short, I realised that the kinds of tests that were applied to the water diviners – properly conducted scientific experiments – needed to be applied to surgery, and we needed to adjust our thinking so that we didn’t react like the water diviners when we were shown the evidence. If I was a water diviner, I would be hanging up my divining rod.

It is not my aim to sensationalise the lack of effect of surgery, nor do I aim to present an exaggerated case in order to make the reader gasp in amazement (therefore recommending the book to their friends). That does not mean, however, that you will not be amazed (nor, hopefully, does it mean that you will not recommend the book to your friends). It just means that this is one of those times when the unembellished truth is interesting and surprising enough. I don’t need to sensationalise the facts; to me, anyway, they are already sensational.

So much for what I am not saying; what I am saying is this: for many complaints and conditions, the real benefit from surgery is lower and the risks are higher than you or your surgeon think. There is a difference between any real, direct effectiveness of surgery and our perception of the effectiveness of surgery. That difference, which we will call the placebo effect, is the reason why we tend to overestimate the true effectiveness of surgery.

This brings up an important distinction that needs to be addressed now because it is central to my message. It is the distinction between observation and experiment, or between perception and reality. There is a tendency to believe what we observe (perception), even when faced with scientific experimental evidence to the contrary. For example, I observe (and perceive) the sun to be rotating around the earth; it is clear to me. But when subjected to scientific inquiry, the numbers don’t add up; the opposite must be true. And like many of the examples provided in this book, that particular belief also took a long time to shake.

When the results of observation and tradition are in conflict with the results of an experiment, what should we believe? Most people trust their own eyes – that is what got us humans so far, from the days before we had even invented science. We didn’t need randomised trials or toxicology tests to tell us which foods to eat and which ones to avoid; we worked it out by observation and tradition. But as any magician, illusionist or mind reader will tell you, we humans are pretty easy to fool, and we can all perceive, and believe, falsehoods.

BLOODLETTING, THE 3000-YEAR-OLD PLACEBO

Bloodletting provides us with a good introduction into the world of the surgical placebo because it is related to the very beginnings of surgery as a craft. It also shows us how strong the conviction of practitioners can be regarding the effectiveness of their procedures. The reasons behind the use of bloodletting as a treatment, despite its lack of effectiveness, apply to many of the other surgical practices discussed throughout this book – with the exception that this one lasted longer than all of them put together.

The story probably dates back to the Mesopotamians and Egyptians, but certainly to the Greeks and Romans. The idea was to purge the body of bad humours, or balance them, or something. (Humours were thought to be the basic substances that made up the body, and illness was thought to be due to an imbalance in those humours.) Although the initial reasons were a bit hazy, by the Middle Ages the ‘science’ around bloodletting had become very elaborate: what part of the body to bleed, what day of the week, the season, the weather and the date, and, of course, how much to take (based on further, ridiculous variables).

Bloodletting was often performed by venesection (cutting a vein), but was also done by other methods such as cutting arteries or using leeches. (In the 1830s, France imported about 40 million leeches per year for medical treatment.) It was responsible for the rise of the surgeon, or the barber-surgeon, to be precise, because they were the ones with the knives. The barbers and surgeons were the ones cutting hair, shaving, lancing boils and performing surgery, so when physicians became too important to do the bleeding themselves, they prescribed bloodletting, to be performed by the barber-surgeons using a lancet (which is how the famous medical journal got its name). The red and white poles found outside barber shops represent the bloody bandages used as a tourniquet to dilate the veins. Later, the surgeons got too important for the barbers and split away, finding new (often placebo) treatments to perform with their knives.

As more accurate diagnoses developed, like pneumonia, cancer, diabetes and jaundice, bloodletting became the treatment for all of them, partly because there was little else to offer. Also, as you will see later in the book, it was a pretty good placebo due to the fact that it was invasive, painful, drastic and shrouded in (pseudo) science.

Eventually, people started to question the effectiveness of bloodletting, and in the 1800s Pierre Charles Alexandre Louis, a French physician, published a paper using scientific methods that concluded that bleeding was ineffective in treating pneumonia. This led to protest from practitioners who ‘knew’ that it worked. One telling article from the American Academy of Sciences in 1858 stated that physicians ‘are not prepared to discard therapies validated by both tradition and their own experience on account of somebody else’s numbers’. That is pretty much what many doctors say today when you show them evidence that their treatments do not work – they’d rather rely on tradition and their own (biased) observations and continue to assume cause and effect where it does not exist (the same response that the water diviners gave when faced with the evidence).

Bloodletting gradually fell out of favour in the 19th century, partly because of increasing scepticism (and scientific reports of its lack of effectiveness) and partly because alternative placebos were springing up, like mesmerism and electricity for physicians – the latter being used to pass currents through parts of the body, usually causing muscle contractions – and an array of new procedures for surgeons. This gave doctors a way out, because, as you will see, not treating people at all is rarely an option.

Surprisingly, bloodletting was still being recommended for certain conditions in textbooks in the 20th century, including (incredibly) as a treatment for shock associated with blood loss during childbirth, and (yes, still) for pneumonia. This shows you how hard it is to kill a tradition.

THE STRUCTURE OF THIS BOOK

Chapter 1 is an introduction into the world of the placebo, with a look at what the placebo effect is and how it works. This includes a discussion on the reasons why placebos work, and how our interpretation of cause and effect can be so wrong, yet is so ingrained; how by being human, we are not necessarily being scientific. This theme is discussed further in Chapter 2, which covers some of the logical fallacies and scientific rules about evidence. This is necessary in order to demonstrate how there is ‘good’ and ‘bad’ evidence, and how the medical community often has double standards when applying scientific criticism to itself and to alternative medicine.

In Chapter 3, I have lightened the mood. We will use all of the facts out there about placebos to build the ultimate placebo, in order to illustrate how surgery fits the bill.

In Chapter 4, we put surgery to the test with examples of operations that have been tested against a placebo. You will see how commonly performed operations are often found to be useless or harmful when properly evaluated.

Chapter 5 covers history, from the earliest surgery to recent operations, looking at operations that have not stood the test of time. All of these operations were commonly performed at some stage in history, and you will see how difficult it can be to change medical practice once it becomes embedded in the body of ‘currently accepted practice’, particularly when the operation has not been subjected to the same rigorous (placebo) testing as the operations listed in the previous chapter.

In Chapter 6, I tread carefully. Given the history of failed operations that were once commonplace, I explore what operations currently being performed might be discarded in the future because of a lack of effectiveness.

In order to better understand the phenomenon that I am describing in this book, Chapter 7 explores the reasons why the system is the way it is: why new yet ineffective procedures keep popping up, why we believe in them, and why they are so hard to eradicate. I will give an overview of what is wrong with the current state of scientific medicine, and the reader will see how ethics and science are distorted in order to maintain our placebos and avoid putting them to the test. I will discuss some possible reasons why we do this, including good old human nature.

Chapter 8 was added in response to a question often put to me: ‘So what?’ Doctors have been using the placebo effect since there have been doctors; as long as people are getting better, why expose the sham? There is a lot wrong with using the placebo effect in surgery, and not just the cost and the potential harm to patients.

In the final chapter, I will offer some solutions under the title of ‘What we can do about it’, and by ‘we’ I am being ambitious by including patients, relatives, surgeons, primary care physicians, administrators, insurers, politicians, and society in general.

To reinforce many of the points I make, I use examples. Some of these examples, along with other topics worth highlighting, appear separately, in breakout boxes. My suggestion is to read them where they appear, as they have been placed to illustrate the points in the neighbouring text.

I have also added some breakout sections called ‘The patient’s perspective’, which cover common perceptions and attitudes that patients (and the general public) have regarding surgery. Having seen many patients, I have found that there are several recurring themes in what patients say, so by addressing these directly I hope to make my message more relevant to the general reader.

Readers may sense that orthopaedic surgery is overrepresented in this book. This is not because orthopaedic surgery is somehow worse than other fields of surgery; it is only because that is what I know best. I hear and read about many questionable procedures from other specialties; some of them have made it into this book and some I have not yet tackled, mainly through lack of detailed knowledge.

I have tried to minimise the use of technical medical or statistical terms, but some use is necessary in order to make the message clear. I have aimed to explain them as they occur.

It is my job to write, edit and review scientific manuscripts. In doing that, every claim must be supported by references or by the data generated in the research. Writing this book, however, is not my job – it is my hobby. I have written this on planes and in hotels, and during late nights at home. I have not included references in the body of the book because it would be distracting and off-putting in a book aimed at the general public. For those interested in the evidence behind my comments, and for those who want to explore this subject further, I have listed many references at the end of the book, grouped by chapter. All of the major studies that I refer to will be included in that section; this will allow you to look at the evidence yourself.

It should also be pointed out that I am not writing this book as a representative of any of the organisations with which I work. This includes my university, the three public and two private hospitals where I work, the various state and federal government committees I sit on, the professional societies that I belong to and their committees and boards, on which I serve. Not because they necessarily disagree with me (although some members do), but because they were not involved in the production of this book and have not seen it.

I hope you enjoy reading this book, but mostly I hope that it causes you to change the way you think about medicine, and surgery in particular. I expect the book to help you to ask the right questions and be more objective (and therefore less human) when weighing up the evidence regarding the risks and benefits of any proposed surgical procedure.